Addiction and Depression: Dueling Demons

The world was shocked, saddened and confused to learn last week that Robin Williams, a phenomenally gifted entertainer and, by all accounts, a sensitive, generous and loving man, had taken his life.

Mr. Williams was always candid about his struggles and proactive in his treatments. But his dignity and integrity remained intact in part because of his honesty, but also because of his hopefulness. The hopefulness that he tragically lost at the end.

Research shows that substance abuse and mental disorders are a dangerous combination.

Dueling Demons

Addiction and depression are tough enough to deal with alone. Together their negative effects multiply. For example, those with depression and those with a substance abuse disorder have about a 10 percent lifetime suicide risk. When combined, the suicide risk skyrockets to about 1 in 4.

Depression also acts as a relapse trigger. In fact, studies have found that it’s the single biggest predictor of alcohol relapse. Drugs and alcohol also appear to interfere with the effectiveness of depression treatment.

The good news is that treatment that working on both issues can lead to good outcomes. Treatment that focuses on one without also dealing with the other, however, is a virtual guarantee of relapse.

When an individual has both depression and an addiction, it is called a Dual Diagnosis. A Dual Diagnosis can be made up of any combination of a mental disorder (anxiety, depression, bipolar disorder) and addiction (drugs, alcohol, sex, gambling). Dual Diagnoses that include depressive disorders are among the most common forms of the problem; in fact, the Journal of Clinical Psychiatryreports that one in three adults who struggle with alcohol or drug abuse also suffers from depression.

Using alcohol

For some individuals who have depression and a substance use disorder, giving up drugs or alcohol can actually make depression worse. If you’ve been using alcohol for years to bury your depressive symptoms, you may find that your depression rises to the surface in sobriety. That’s why it’s so important to receive integrated treatment for both depression and substance abuse at the same time.

Without treating the depression that drives your addiction, or vice versa, you’re likely to go back to your addictive behaviors or to experience a return of your depressive symptoms as soon as you finish rehabilitation. In many cases, people who have depression and substance abuse drop out of conventional rehab programs because sobriety is too much to handle without the right level of therapeutic support.

Support, encouragement and motivation are essential tools in the battle against depression and substance abuse. Clinical depression can drain your energy and make you feel that rehab is a hopeless cause. Individual counseling, peer group support and family counseling can give you the strength you need to continue your recovery journey in spite of the challenges you face.

It’s tempting in situations such as these to write off attempts at treatment. Why bother, some ask, when this is the outcome?

It’s important to remember that although mental health and substance abuse treatments may not always result in continuous remission, they can drastically improve quality of life and lead to stretches of highly productive living. In Williams’ case, his early alcohol and drug use was followed by 20 years of sobriety before a return to drinking in 2003. This was followed by treatment and a return to sobriety in 2006. Just before his death, suffering from severe depression, he checked himself back in to treatment for “fine-tuning,” not because he had again relapsed, he said, but because he felt he needed the support. That he ultimately succumbed to his depression says more about the power of the illness than about any treatment shortcomings.

The reality is, there is no simple cure for depression or for addiction. The best we have is treatment that can be lifesaving for many – but sadly, not for all.

One of the biggest failings of modern treatment for depression and addiction is that people aren’t educated about the need for ongoing treatment. Instead, there is a mythology that we will take a few weeks of antidepressant pills or go to rehab for 30 days and come home cured. It doesn’t work that way.

The reality is that after an initial treatment period, only about 1 out of 3 people with depression is in remission, 1 out of 3 people is improved but not in remission, and 1 out of 3 is no better than when they started. The greatest success is seen when therapy and medication are combined in long-term treatment. For those with recurrent depression who don’t receive ongoing care, the likelihood of relapse within two years is close to 100 percent.

With substance use disorders, treatment should be delivered and success measured over the long-term. A substantial group will maintain continuous abstinence but a larger group will be able only to change their behaviors in ways that significantly reduce the impact of drugs and alcohol on their lives. This may mean sobriety comes in spurts, but each period should be counted as a victory. It may not be the best outcome, but it does mean a life changed for the better.

Depression isn’t a weakness.

I’m always startled by the misunderstandings of the nature of depression that seem to rise to the forefront in tragedies such as these. So it bears repeating: depression is a brain disorder that is most likely caused by a combination of genetic, biological, environmental and psychological factors. It is not something you snap out of any more than you snap out of cancer. It’s not a refusal to be grateful for all of the blessings of life. It’s not a character flaw. And it’s not something that wealth, fame, international acclaim or even respect and love can protect you against.

With each bout of depression, the sufferer may feel a type of emotional blunting or, worse, find his mind crowded with all the old bad feelings – hopelessness, anxiety, preoccupation, dread, fear, self-loathing – often leading to sleep and appetite issues and spurring a turn to alcohol or other drugs for relief.

Williams, who had sought treatment for depression in the period leading up to his death, also “Fresh Air” (link below) and told Terry Gross and discussed his mood swings.

In Robin Williams’ case, we are again reminded of the strength of this foe. Treatment, therapy and medication for depression can help most and save many. But sometimes, despite mighty efforts, there is no Hollywood ending.

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